Isotretinoin, the most effective drug for the treatment of acne, can sometimes raise some doubts for patients to whom it is recommended.
For general information about this medicine and its side effects, you can click here.
Here are some common questions that arise before starting treatment:
I have heard that at the beginning of treatment with isotretinoin acne always gets worse, is that true?
No. Worsening of acne at the beginning of treatment with this drug can occur in up to 32% of patients, according to some studies, although most cases are of low intensity and tolerable. Severe worsening occurs only in 4.5 – 6% of cases, and is more likely when the following variables are met: severe basal acne, presence of macrocomedones (“giant pimples”) on the face or trunk, facial nodules, high dose of isotretinoin from the beginning of treatment (1 mg/kg/day) and/or male gender. The incidence of an acne breakout at the start of treatment is minimal if therapy is started at a dose less than or equal to 0.2 mg/kg/day. Your dermatologist should inform you about how treatment is recommended.
I’ve read that the higher the dose of isotretinoin you take each day, the more effective the treatment and the more likely it is to cure acne for good. Is that true?
No. According to recent publications, the effectiveness of the treatment is the same whether the daily dose administered is low or moderate (e.g., 20 mg/day) and the therapy is maintained long enough to reach the accumulated 120 – 150 mg per kilo of the patient’s weight. This is valid whether the acne is mild or moderate. In patients with severe acne, the clinical response is better at high doses.
Acne treatment with isotretinoin always peels your skin and it flakes.
False. Xerosis (dry skin) is an effect of the action of this drug, as it reduces the activity of the sebaceous glands, so less sebum is poured into the skin and it is not as hydrated. However, this phenomenon is proportional to the daily dose of medication, so if an optimal dose is calculated for the patient, the effectiveness of the treatment is maintained, making the adverse effects less likely and intense. A low or moderate dose does not cause intense peeling of the skin.
Some friends have been treated with isotretinoin for 6 months and others for up to a year or more. Why this difference?
Treatment with isotretinoin has to accumulate a drug dose of 120 – 150 mg of drug per kilo of patient weight so that the probability of acne recurrence is minimal after the end of therapy. Reaching this dose can be done at a higher daily dose for a shorter time, or vice versa. The adverse effects of this drug have an incidence and intensity proportional to the daily dose: the higher the dose, the more frequent and intense the adverse effects. To date, studies have shown that performing the treatment at low or moderate doses has the same effectiveness and probability of acne relapse as high doses, but with less frequent adverse effects. In cases of mild or moderate acne, it is possible to achieve a complete cure even without reaching a total dose of 120 mg/kg, especially if a topical retinoid cream is used daily at the end of the treatment. Performing one type of therapy or another depends on the patient’s preference and the agreement reached with their dermatologist.
Is it possible that after the correct treatment with isotretinoin the acne will come back? Do I sometimes have to do the treatment more than once?
Yes. It is not common, but it has been estimated that up to 6-32% of patients who undergo full treatment with this drug may have acne relapses up to two years after the end of treatment. The probability of this occurring does not seem to be related to age or the initial severity of acne, although some series do find the male gender as a risk factor for relapse. It is recommended, to reduce this probability, that after finishing isotretinoin, a specific retinoid cream be used applied every night, which will be recommended by your dermatologist if appropriate.
When you take isotretinoin, your nose bleeds. Is it because it alters blood clotting?
No. Firstly, epistaxis (nosebleeds) are not constant, but rather infrequent in patients taking this drug. It seems that the bleeding is only due to the dryness that occurs in the nasal mucosa, since isotretinoin has no effect on blood clotting parameters. In fact, it is possible that some patients experience a minimal increase in platelets in the blood, without this implying an increased risk of thrombotic phenomena.
Is it true that when you are taking isotretinoin you have to have a blood test every month throughout the treatment?
Not necessarily. According to recent studies, if the lipid profile (cholesterol and triglycerides) is normal at the beginning and in the first analysis after the start of therapy, it is not strictly necessary to perform monthly tests but every 2-3 months. It has been observed that it is only justified to order them monthly when the patient’s lipid profile is at the high limit of normal.
What time of day should you take isotretinoin?
No study has been carried out on this aspect, but what should be taken into account is that this drug is fat-soluble (it dissolves better in fat), so it is advisable to take the drug with food, and if possible, a large one. It has been proven that the intake of this drug during one of the main meals of the day increases its bioavailability and, therefore, improves the effectiveness of the treatment and reduces the probability of acne relapse at the end of therapy.
I’ve heard that some people, instead of taking isotretinoin every day, take it only some days of the month. Is this type of treatment more effective?
No. In fact, it is preferable to carry out continuous therapy at low doses than to take the drug only one week a month: it seems that the latter therapeutic regimen is related to an increased risk of acne relapse once it is over and to a greater difficulty for the patient to remember to take the drug correctly.
REFERENCES
· Demircay Z, Kus S, Sur H. Predictive factors for acne flare during isotretinoin treatment. Eur J Dermatol. 2008 Jul-Aug; 18(4):452-6.
· Oral isotretinoin in different dose regimens for acne vulgaris: a randomized comparative trial. Agarwal US, Besarwal RK, Bhola K. Indian J Dermatol Venereol Leprol. 2011 Nov-Dec; 77(6):688-94.
· Low-cumulative dose isotretinoin treatment in mild-to-moderate acne: efficacy in achieving stable remission. Borghi A, Mantovani L, Minghetti S, Giari S, Virgili A, Bettoli V. J Eur Acad Dermatol Venereol. 2011 Sep; 25(9):1094-8.
· Kaptanoglu AF, Uncu M, Ozyurt S, Hincal E. Effect of isotretinoin on prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT). J Dermatolog Treat. 2013 Aug; 24(4):272-4.
· Ertam I, Alper S, Unal I. Is it necessary to have routine blood tests in patients treated with isotretinoin? J Dermatolog Treat. 2006; 17(4):214-6.
· Alcalay J, Landau M, Zucker A. Analysis of laboratory data in acne patients treated with isotretinoin: is there really a need to perform routine laboratory tests? J Dermatolog Treat. 2001 Mar; 12(1):9-12.
· Sell R, Sell R. Double-blinded, vehicle-controlled proof of concept study to investigate the recurrence of inflammatory and noninflammatory acne lesions using tretinoin gel (microsphere) 0.04% in male patients after oral isotretinoin use. Dermatol Res Pract. 2012. Epub 2012 Apr 19.
· Del Rosso JQ. Face to face with oral isotretinoin: a closer look at the spectrum of therapeutic outcomes and why some patients need repeated courses. J Clin Aesthet Dermatol. 2012 Nov; 5(11):17-24.
· Boyraz N, Mustak PK. Comparison of the efficacies of intermittent and continuous low-dose isotretinoin regimens in the treatment of moderate acne vulgaris. Int J Dermatol. 2013 Oct; 52(10):1265-7.